Cultural aspects of health and healthcare have been part of nursing and public/community health for the past 100 years. Other health professions have more recently begun to recognize its importance, having been stimulated by the US federal Office of Minority Health, increased research funding, and a renewed emphasis on community and public health. Cultural competence is currently being suggested as a way to reduce health disparities among racial, ethnic, uninsured, and underserved US populations.
In this issue, a broad definition of culture guided the selection of articles in which race/ethnicity, gender, age, and disability intersect with health issues. Despite a focus on culture, equally strong influences on family and community health are the economic, social, political, and environmental contexts in which people live their lives. Culture may be relatively more important in some situations and less important in others, for example, an ethnic group that lives in poverty, a "dangerous" community, or in a pollution-ridden industrial area. Several articles highlight these contextual issues.
Five of the 7 articles are research reports; the sixth is a "think piece" on a participatory action study and the seventh describes ethnic-specific genetic diseases. The intersecting themes include cross-cultural healthcare communication, family support, health risks, community and ecological context of health behavior, and mental health issues. The populations include a mixed sample of immigrants, Punjabi women, African American young men, African American adolescent girls, Puerto Ricans, Jews, and Taiwanese.
The articles are arranged in 3 rough categories: healthcare communication, primary or secondary prevention in community contexts, and mental health. In the first article, Oliffe and colleagues reflect on the experiences of "nondominant culture" Canadian cancer patients' communication with their "Anglo" healthcare providers. They found striking issues around autonomy, responsibility, and informed consent in their Chinese, First Nations/Aboriginal, Persian, Jamaican, Dutch Indonesian, and Filipino participants. The second article, by Balneaves and colleagues, describes how Canadian Punjabi immigrant families respond to a diagnosis of breast cancer and support their family member. Similar to Oliffe and colleagues' study, there are clear implications for including family members in communication about cancer, and the findings suggest family-centered models of care.
The next 3 articles have implications for community-level prevention. Cooper and Guthrie use an ecological framework in which to view social, environmental, and relational contexts that influence urban African American adolescent girls' health-promoting and health-compromising behaviors. They found considerable variation, which characterizes all ethnic groups, but a strong finding was that a close mother-daughter relationship was associated with less substance abuse, risky sex, and violent behavior. Foster and Stanek describe an exploratory community participatory research project that began with university faculty members' concern about HIV in a Puerto Rican community in Massachusetts. Ongoing faculty and community members' discussions and exploratory qualitative interviews revealed that the community was more concerned about intimate partner violence than about HIV. Weinstein's comprehensive and practical article begins by describing genetic disorders that affect Ashkenazi Jews, including a useful glossary. Prevention is addressed through her description of screening, testing, and counseling, including specific cultural values that must be considered when working with Jewish patients. While she focuses on nursing roles, her suggestions clearly are applicable to other health professionals who work with Jewish clients.
The last 2 excellent qualitative studies focus on mental health issues. Kendrick and colleagues used focus groups and individual interviews to identify experiences and perceptions of depression among 18-25-year-old African American men. These middle class and well-educated young men not only identified depression as a fact of life but also vividly described racism as a powerful interpersonal stressor, a contributing factor. Tzeng identifies and illustrates fan, a culturally constructed way of expressing emotional distress in Taiwan. On the basis of interviews of people who had attempted suicide, she shows that their experiences are not understood and they are not supported by family, community, and mental health professionals.
Despite all articles having a basis in a cultural group or cultural characteristics, they differ in emphasis-a health issue in a specific group, family support or nonsupport, or foregrounding the influence of the community and the broader social environment. But all have important and intersecting implications, including policy, clinical, and research implications for family and community health. Most articles illustrate the importance of participatory and qualitative research to uncover striking health and healthcare issues to guide future research and healthcare planning. They illustrate the importance of recognizing cultural and experiential variation within a specific ethnic group, a community, and the multiple factors that impact specific groups. And they emphasize the need for community and clinical healthcare professionals to provide more culturally competent care through increasing their knowledge and altering their communication to better serve their clients.
Juliene G. Lipson, PhD, RN, FAAN
Department of Community Health Systems, University of California, San Francisco